New Patient Intake Form r .pdf

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Original filename: New Patient Intake Form-r.pdf
Title: CONFIDENTIAL PATIENT INFORMATION
Author: Russell Rosen

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Long Point Family Chiropractic

Tel: (843) 856-8888
Fax: (843)856-2526
498 Wando Park Blvd, Ste 350
Mt. Pleasant, SC 29464

Sean Gaffney, DC

www.longpointchiropractic.com

CONFIDENTIAL PATIENT INFORMATION
Personal Information
Full name:

Date:

Address:
Street

City

State

Home phone:

Work phone:

Cell phone:

Email address:

Zip

Best time/place to contact you:
Date of birth:

Age:

No. of children:

Pregnant?
Weight:

Height:
Driver’s license number:
Marital status:
Occupation:

M

S

W

Yes



No



Spouse/guardian name:

D

Employer’s name & address:
Spouse’s Occupation/Employer:
Name of person responsible for account:
Do you have insurance that covers Chiropractic care?

Do you have Medicare coverage?

Yes
No
Name of Insurance Company:

Yes

Insurance Policy number:
Insurance Company address:

Insurance Company phone number:







No



Who may we thank for referring you? __________________________________________________________________________

Addressing What Brought You Into This Office:
If you have no symptoms or complaints and are here for Chiropractic Wellness Services, please skip to the “General Health History”.

Health Concerns
Please list your health concerns
according to their severity

Rate of severity
1 = mild
10 = worst
imaginable

When did this
episode start?

If you had this
condition
before, when?

Did the problem
begin with an
injury?

% of the time
pain is
present

1.
2.
3.
4.
Is your pain dull? Or is your pain sharp? Does it radiate anywhere? If so, where?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Since the problem started is it: About the same?



Getting better?



Getting worse?



What have you done for this condition? Was it of benefit?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Rosen Coaching, Inc. Copyright © 2003 (808) 878-8384

I do (do not) have a family history of this or similar symptoms (Please explain):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Which activities aggravate your condition? ________________________________________________________________________
__________________________________________________________________________________________________________
Other doctors you have seen for this condition:







“Limited Scope” Chiropractor (focuses mainly on neck and back pain)
“Wellness” Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns)
Medical Doctor
Dentist
Other (please describe)
Doctor’s details:
Name:

Address:

When did you see them?
What did they say was wrong?
Did it help?

What did they do?

Name:

Address:

When did you see them?
What did they say was wrong?
Did it help?

What did they do?

Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc?
(i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.) If so, what?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Is this condition interfering with any of the following:
Work



Sleep



Daily routine



Sports/exercise



Other

□ (please explain):

General Health History
Often times, accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this as it
will help us help you!
Have you had any surgery? (Please include all surgery)
1. Type:

When?

Doctor

2. Type:

When?

Doctor

3. Type:

When?

Doctor

4. Type:

When?

Doctor

Have you had any accidents and/or injuries: auto, work-related, or other? (Especially those related to your present problems).
1. Type:

When?

2. Type:

When?

3. Type:

When?

Hospitalized? Yes



No



Hospitalized? Yes



No



Hospitalized? Yes



No



Have you ever had x-rays taken?
Rosen Coaching, Inc. Copyright © 2003 (808) 878-8384

Area of body:

When?

Do you wear orthotics or heel lifts? Yes



No

Where?



Current Medicines and Supplements
Please list any medications/drugs you have taken in the past 6 months and why: (prescription and non-prescription)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Please list all nutritional supplements, vitamins, homeopathic remedies you presently take and why:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Are you interested in knowing more about how your nutrition (food you eat) affects your overall
health and well-being?

Yes

If dietary changes are indicated would you be willing to make changes in your diet?

Yes

Would you take whole food supplements if indicated?
If specific exercises or stretching would help would you consider adding them to your program?
If reducing stress would you help you would you like to know ways to reduce stress?




Yes □
Yes □
Yes □



No






No
No
No
No

Maybe




Maybe □
Maybe □
Maybe □
Maybe

Diet
Please circle any dietary selection that is appropriate for you, and grade according to the following scale:
D - Consume this daily | FD - Consume this a few times per day | W - Consume this weekly | FW - Consume this a few times per week
FM - Consume a few times per month (less than weekly) | M - Consume this monthly | O - Do not consume this
Alcohol

Eggs

Fasting

Artificial Sweetener

Tobacco

Fruit

Diet food

Weight Control Diet

Coffee

Beef

Refined Sugar

Raw Vegetables

Soda

Poultry

Fish

Whole Grains

Fried Foods

Organic foods

Seafood

Dairy

Cooked or canned vegetables
The type of diet I usually follow is classified as: __________________________________________________________________

Past Health History
Please mark the following conditions you may have had or have now (- have had + have now):

□ Alcoholism

□ Allergy

□ Anemia

□ Arteriosclerosis □ Arthritis

□ Asthma

□ Back Pain
□ Diabetes

□ Cancer
□ Diarrhea

□ Cold Sores
□ Eczema

□ Constipation
□ Emphysema

□ Depression
□ Gall Bladder

□ Gout

□ Headaches

□ Heart Attack

□ Heart Disease

□ Irregular Periods □ Low Blood Sugar

□ Malaria

□ Measles

□ Miscarriage
□ Pleurisy

□Mumps
□ Polio

□ Neck Pain
□ Rheumatic

□ Stroke

□Multiple Sclerosis
□ Pneumonia
□ Thyroid Problems

□Tuberculosis

Fever

□ Ulcers

□ Convulsions
□ Epilepsy
□ High Blood
Pressure

Problems

□ HIV (Aids)

□ Menstrual Cramps

□ Migraines

□ Nervousness
□ Ringing in ears

□ Neuritis
□Sinus

□ Venereal Disease

Problems

□ Whooping
Cough

Other (please explain) ________________________________________________________________________________________
__________________________________________________________________________________________________________
Rosen Coaching, Inc. Copyright © 2003 (808) 878-8384

Stressors
Because accumulation of stress affects our health and ability to heal please list your top three stresses (you have ever had) in each
category:
1.

Physical stress (falls, accidents, work postures, etc.)
a. _________________________________________________________________________________________
b. _________________________________________________________________________________________
c. _________________________________________________________________________________________

2.

Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.)
a. _________________________________________________________________________________________
b. _________________________________________________________________________________________
c. _________________________________________________________________________________________

3.

Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.)
a. _________________________________________________________________________________________
b. _________________________________________________________________________________________
c. _________________________________________________________________________________________

On a scale of 1-10 please grade your present levels of stress (including physical, bio-chemical and psychological or mental/emotional):
At work:

At home:

At play:

On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your:
Eating habits:

Exercise habits:

Sleep:

General health:

Mind set:

How do you grade your physical health?
Excellent



Good



Fair



Poor



Getting better



Getting worse





Poor



Getting better



Getting worse



How do you grade your emotional/mental health?
Excellent



Good



Fair

Is there anything else which may help to better understand you which has not been discussed?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________
Why are you here at this point in time?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________
____ I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems
necessary.
I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date.

Print Patient Name: __________________________________________________________

Date: _________________________

Signature: _________________________________________________________________

Rosen Coaching, Inc. Copyright © 2003 (808) 878-8384


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